An Episcopal (Anglican) Chaplain in the Saint Luke's Health System of Kansas City, reflecting on work and faith and life. NOTA BENE: my opinions are my own and do not represent the Episcopal Church or the Saint Luke's Health System.

Tuesday, August 21, 2007

A (Poor) Moral Argument About Universal Health Coverage

Well, I was bouncing around through the Net, when I ran across this post by Megan McArdle. She has written for The Economist, and her blog is at TheAtlantic.Com. She makes some statements about moral arguments for a national health plan, and specifically for a single-payer national insurance plan.

She poses this as a transfer of wealth from the young (as a class less likely to be sick, but also less wealthy) to the elderly (as a class more likely to be sick but also more wealthy). In her argument she undermines her own categories, acknowledging that the young and healthy will, unless they die young, eventually become old, and presumably less healthy. At the same time, she refuses to reach the obvious conclusion of that problem: that her arbitrary classes have more in common than they have that distinguishes them.

And since that is the case, arguing about wealth transfer is misleading. Indeed, it misses the fact that such wealth transfer is already taking place. Wealth is transferred from those who have insurance of whatever form (private or government funded) to those who don’t. Institutions cost shift, raising charges for those who can pay to cover the expenses of those who can’t. The same thing happens in any other industry, really: the local convenience store has a certain latitude in the budget to pay for losses due to shoplifting and accidental damage. In health care, the costs come from unreimbursed care provided to those without insurance. In health care, the wealth transfer takes the form of higher charges from health care providers, leading both to higher insurance premiums and higher co-pays.

She does acknowledge one moral argument for a single player health plan: “no one should die, or suffer unduly, because they don't have the money to pay for treatment.” Well and good; but she misses several other considerations.

First, while a single-payer plan is the most common model to be raised, it isn’t the only model. There are mixed models of government involvement with private insurers to provide universal coverage.

Second, her model is still based on paying to treat pathology rather than to prevent it. It has been amply demonstrated that the cost of paying to treat illness is significantly higher than the cost of primary care to prevent it.

And it is this last that highlights my greatest concern about many economic arguments against universal coverage for health care. Most of the arguments seem to have no sense of investment. They don’t consider long term savings in public health that prevents illness (including such concerns as the pandemics we are all anxious about these days), or that keeps the healthy working and productive. It seems to me to reflect some of the worst of our recent economic swings: it’s all about short-term profits instead of long-term value.

Read Ms. McArdle’s article. She is at least interested in moral discussion about universal health coverage. She’s interested in getting beyond the political expediencies of “Everyone should be taken care of,” or, “Yes, but not out of my wallet.” We need to bring such discussion to the public sphere. We just need to do it better.

As a hospital chaplain you are in a unique position to broker the conversation between scared physician and scared patient. I, too, am a chaplain in hospitals and in other places. I'll suggest here that the conversations about health care are badly clouded by the vested interests of parties not actually participating in the delivery of health care and I offer part of one example; only part of one, though, in the interests of brevity and readability.

Mmm. Beyond suggest, I’ll claim that the sums of money involved in these investments are big enough to encourage some actors actually to promote false fear to secure their places in the revenue stream. The fear factor, also, should heighten the interest of baptised believers who believe the Christ who told the disciples in their boat, “Take courage, it is I; do not be afraid.” If the “I” that is speaking is indeed ‘the way, the truth, and the life,’ then what must a deliberate hawking of false fear and false truth be to us who follow Christ, and to our Abramic siblings?

Most physicians just want to carry on with medical practice, it's what they want to do and what they're good at. They're neither stupid nor mean. (There are significant exceptions, of course.) Where I do find them lacking is in their understanding of most everything else, which is not surprising at all given the archaic way in which they are trained. Okay, I've said that. And also alluded to another soapbox.

Now, next, look in the phone book or call your local county bar association and get the hard numbers on the number of attorneys in medical malpractice practice. Of that number, ask what percentage are defence and what percentage are plaintiff. That number will tell you where the money is. In my county it is 85% defence.

Med-mal defence are the folks on retainer by purveyors of medical care. These are the folks with a high vested interest in retaining the steady retainer with minimum output. They're the folks who promulgate the idea that a doc's malpractice premiums are tied to injured-patient awards. Many are enthusiastic about ‘tort reform’ “people's initiatives” to 'limit clogging our courts with frivolous lawsuits.’ They pimp their docs hard to encourage patients to sign petitions. Tort reform enthusiasts do not freely acknowledge the considerable safeguards against frivolity that are already in place.

My own personal campaign is distributing the well-known and well-published GAO report on the influences behind changes in medical malpractice premiums. According to that report, premiums are increased solely in response to the performance of the stock markets. That is to say that when an insurance company is not making as much money as it hopes to through its investments in other organizations, it raises premiums. With respect to awards to injured patients, according to the report, the fact is that these have been going down in size. The defence attorney’s hope, of course, is that these payments will get so low that it will no longer be tenable for a plaintiff attorney to invest in a case.

In many places, it is close to that already. It takes about six years and at least $100,000 for a med-mal case to be decided in court. The patient is usually expected to put about $30,000 of that up front. The investment is for such things as obtaining copies of medical records, hiring medical/legal assistants to review them for evidence, hiring out-of-state doctors to first review the case, second, write a report, third give a deposition, and fourth to appear in court ($250/hr each for 1-3 docs, usually 20 hrs each doc to review + 5-10 hrs deposition and court appearance, + travel/lodging), and the law office’s salaried time in doing the legal and medical research. $100,000 doesn’t go very far, especially up against a multibillion dollar industry determined to put you out of business!

When judgment is obtained, the dollar amount requested necessarily has to include a) expenses b) lifetime medical care because a patient who has ever filed suit is directly or indirectly shunned, c) loss of earnings, both real and projected, and d) the law office’s charges. Note the unintended bias: Working class people don’t have $30,000 front money and tend not to have a multimillion dollar residual earning potential, and older people do not have enough projected income left to make the investment viable for a plaintiff attorney. Exempli gratia, a 35 y/o earning $70,000/a is disabled; this means a direct financial loss of $2,100,000 not including benefits, pension, pay raises, cost of living and so forth. This would support an attorney’s fee of at least $700,000. On the other hand, if this same injured person is 60 years old (or earning minimum wage) there is a loss of just $350,000, which would support a fee of only $120,000 for exactly the same amount of work.

Note that this simplistic ‘request for judgment’ does not factor in such things as the diminution of the quality of life, or of punitive damages. What if the injury leaves the patient in pain, nauseated, and foggy headed with opiates for forty years? What about the children who’ve effectively lost a parent and the spouse ditto? What if a business fails because of the malpractical injury? OTOH, should a paediatric surgeon be held liable for “majority + seven” i.e. until the patient is seven years past majority? (Here we step off into speculating on the art:science ratio of medical practice and the question of artistic licence of it all.)

Again, this isn’t about med-mal attorneys and their evil ways. It is about the hazards of placing basic human need at the mercy of market forces and of being less than alert when large sums of money are changing hands.

That, IMHO, is the immorality of insurance systems’ ultimately providing medical care: It places priceless human life in the market place, thereby giving the lie to our understanding of ourselves as a moral people which values human life as priceless.

The right to life, liberty, and the pursuit of happiness is a fundamental human right. It is the moral ground we claimed when we revolted against the British monarchy. We Americans have also already proclaimed as ‘self-evident’ that it is the government’s business to secure these rights and that governments which fail so to do should be altered or abolished.* Isn’t it time we put our money where our mouth is?

*“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.--That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, --That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”

Well, Susan, I largely agree, especially that it is the dependence on market forces that hampers change. We need to confron the myth of the automatic capacity of market forces to optimize results. Too many of the actors aren't as committed to "optimizing" beyond themselves.